Allied Health Professionals

8. Healthy Eating

The patient will be able to state measures to take to maintain healthy eating habits.


Following pelvic pouch surgery there will be a period of adaptation that may take up to one year. The pouch storage capacity will increase and the number of bowel movements per day will decrease. Stool consistency will thicken over time. Diet and medication can help to improve pouch function. It will be important for patients to resume normal, healthy dietary patterns over time.

General dietary tips:

  • Develop regular eating patterns that allow the pouch to adapt and function in an appropriate manner.
  • Smaller meals may be better tolerated, but in this case it is important to eat more often to ensure an adequate intake.
  • Eat meals in a relaxed environment. Foods should be chewed slowly and thoroughly.
  • Drink plenty of fluids each day (i.e. more than eight cups of liquid per day).
  • Gradually add "potential" problem foods to the diet to see how food is tolerated.
  • Foods that cause a problem should be temporarily eliminated, and then reintroduced at a later date.
  • Strive for a balanced diet. Choose food from all food groups.
  • Include foods and fluids high in potassium and salt during periods of stool looseness and frequency.


Foods or beverages that may cause stool to become loose or to increase pouch output:

  • apple juice
  • prune juice
  • spinach
  • highly spiced foods
  • raw fruit and vegetables
  • baked beans
  • green beans
  • cabbage
  • broccoli
  • caffeinated beverages
  • red wine
  • beer
  • milk
  • chocolate


Foods that thicken stool or decrease pouch output:

  • white rice
  • pasta
  • bread
  • bananas
  • applesauce
  • buttermilk
  • cheese
  • marshmallows
  • toast
  • tapioca pudding
  • potatoes
  • creamy peanut butter
  • yogurt


Foods that may contribute to anal irritation:

  • popcorn
  • nuts
  • coconut
  • certain raw fruits and vegetables
    (eg. oranges, apples, coleslaw, celery and corn)
  • Chinese/oriental vegetables
  • dried fruits (eg. raisins, figs)
  • foods with seeds
  • spicy foods
  • citrus juices

Keep in mind that everyone's response following the pelvic pouch surgery is unique. What may upset or create problems for one individual may be well tolerated by another. Tolerances may change with time, so periodically patients should be encouraged to try small quantities of any foods currently being avoided.

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7. Fertility

The patient is able to discuss concerns regarding pregnancy and fertility following the pelvic pouch procedure.


For Women

Some women may experience increased fertility due to removal of the inflamed colon. Unfortunately, others may have decreased fertility from adhesions or scar tissue that develops after the removal of the rectum. Additionally, with pregnancy, the method of delivery remains controversial (C-section versus a vaginal delivery) because any injury to the anal sphincter (control) muscles may lead to the inability to control stool. It is important to inform the obstetrician of the changes in anatomy as a result of the pouch so he/she can perform a C-section should any problems arise during the vaginal delivery.

For Men

Impotency and retrograde ejaculation (the sperm going into the bladder instead of out the end of the penis with ejaculation) are serious but relatively rare occurrences. It is essential that your surgeon be aware of any difficulties with intercourse following pelvic pouch surgery.

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5. Emptying Problems

The patient is able to state measures to alleviate emptying problems.


Looseness and frequency of stool is not uncommon during the early months following pelvic pouch surgery. It generally takes at least six months for the pouch to "adapt" - begin functioning and acting like a pouch or reservoir. It is extremely important to keep the skin around the anus clean, dry and intact.

Suggestions

Allowing time for movements is an important factor in successfully emptying of the pouch. The rectum normally contracts to squeeze stool out like you would squeeze toothpaste from a tube. This is why going to the bathroom is normally fairly quick and easy. A pelvic pouch, however, has to empty using gravity and this can take time. If individuals with pouches spend only a few seconds on the toilet they may only empty stool from the bottom quarter of their pouch. Then, 10 minutes later stool in the upper part of the pouch falls into the lower part and there is another trip to the toilet. It is suggested that a patient sit and rest. Allowing the pouch to empty more completely will decrease the number of toilet visits.

It has been suggested that Imodium™ or Lomotil™ is helpful in slowing the bowel but Imodium may also create additional problems. By thickening the stool too much and by reducing peristalsis even further, it may make emptying the pouch more difficult and make matters worse. Sometimes a semi-liquid stool is an advantage.

Individuals have also reported that shifting on the toilet, standing and sitting allows for a better, more complete evacuation.

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6. Sexuality Concerns

The patient is able to discuss concerns regarding intimacy and sexuality.


Following pelvic pouch surgery, some women will initially complain of pain with intercourse and vaginal dryness. The pouch sits very closely to the vagina and if the pouch is full, pressure can be placed in the region of the vagina. Ensuring the pouch is emptied before intercourse and experimenting with different positions may help alleviate the discomfort.

Vaginal dryness can be due to hormonal changes following surgery. If it occurs, it is usually temporary and can be remedied through use of vaginal hydrating gels. There is no time restriction in terms of resuming sexual relations - the key is to be ready and comfortable. It is important to keep open dialogue and have the patient share concerns/fears with his/her partner.

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4. Pouchitis

The patient is able to state the definition of pouchitis, signs and symptoms of pouchitis, diagnosis, occurrence, causes, treatment and prevention for pouchitis.


Pouchitis is an inflammation of the mucosa, or lining of the pouch.

Symptoms

The main symptom for most patients is an abnormally large number of stools: an increase from 4 to 6 (on average), or more. Patients may also experience rectal bleeding, abdominal cramping, a sense of "urgency" before having a bowel movement, and fever.

Diagnosis

Patients who have any of the symptoms listed above could have pouchitis. However, several other conditions also could cause similar symptoms. These include irritable bowel syndrome, small bowel obstruction from scar tissue, narrowing of the join (anastomosis) between the anus and the pouch, an intestinal infection with bacteria or parasites, and Crohn’s disease. For this reason, patients whose symptoms suggest pouchitis should be seen by either their colorectal surgeon or gastroenterologist or have a flexible sigmoidoscopy (examination of the pouch with a flexible lighted instrument). At this time, biopsies (tissue samples) of the pouch should also be obtained. In patients with pouchitis, flexible sigmoidoscopy will reveal inflammation, similar to that found in ulcerative colitis, in the mucosa of the pouch. When examined under the microscope, the biopsies will also show inflammation. If inflammation is not present, then other causes for the symptoms should be considered.

Occurrence

The cause of pouchitis is not known. Researchers have suggested several theories; an excess of bacteria in the pouch related to stool stasis; a recurrence of inflammatory bowel disease in the pouch and misdiagnosis of ulcerative colitis. In a minority of patients, it may be difficult to differentiate between Crohn’s disease and colitis. Problems that may occur postoperatively could be related to the fact that the patient has Crohn’s disease.

People who suffer from pouchitis often improve with antibiotics, which suggest that bacteria are an important factor in the development of this condition. Pouchitis occurs more commonly in people with extraintestinal problems associated with ulcerative colitis (e.g., arthritis or abnormalities of the liver, skin, or eyes). These findings suggest that pouchitis may be a new type of IBD, which recurs in the pouch. Most patients with pouchitis do not have Crohn’s disease.

Research is being done to identify the cause of pouchitis. Some investigators are looking for “triggering” bacteria or disease markers, such as antibodies. One early finding is that pouchitis is more common in ulcerative colitis patients who have antineutrophil cytoplasmic antibodies (ANCA) in their blood. Not everyone who has ANCA will get pouchitis. The most likely cause is two fold: a genetic susceptibility to both ulcerative colitis and pouchitis, combined with a “trigger,” such as bacteria, within the stool in the pouch.

Treatment

Antibiotics are the most common treatment for pouchitis. The most commonly used antibiotic is metronidazole (Flagyl). Most, if not all, patients initially improve after taking metronidazole, usually within one or two days. The length of treatment is usually one-two weeks. A small minority of patients may require continual treatment for chronic pouchitis.

Italian researchers are reporting that high doses of probiotics appear to be an effective therapy for maintaining remission in patients with chronic pouchitis who are in remission. Other studies have shown that 5-aminosalicylates, steroids, immunomodulators, anti-TNF-alpha therapies, may also be effective in treating recurrent or chronic pouchitis.

Prevention

Helpful suggestions include a liberal intake of fluids to keep the system flushed, and yogurt that includes the healthy bacteria acidophilus (yogurts that contain the living strains of L. bulgaricus and S. thermophilus are more appropriate). Another suggestion is not to allow stool to stay inside the pouch for long periods of time. Going to the bathroom prior to sleep is recommended.

Pouchitis does not affect everyone with the pelvic pouch. Even people who do develop pouchitis report that their quality of life is better than when they had ulcerative colitis. In almost all cases, having an ileostomy can eliminate the problem of chronic pouchitis.

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